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Fabi M, Chessa MA, Panizza D, Dormi A, Gazzano A, Patrizi A, Bardazzi F, Rocca A, Filice E, Neri I, Lanari M. Psoriasis and Cardiovascular Risk in Children: The Usefulness of Carotid Intima-Media Thickness. Pediatr Cardiol 2022; 43:1462-1470. [PMID: 35316356 DOI: 10.1007/s00246-022-02869-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 03/04/2022] [Indexed: 02/06/2023]
Abstract
Psoriasis is a skin disorder which mostly affects adults, beginning in childhood in almost one-third of patients. In adults it is associated with increased risk for cardiovascular diseases (CVD), while this association is still debated at younger age. Our aim was to evaluate the association between psoriasis and metabolic markers and cardiovascular findings in this age group. Twenty consecutive patients previously diagnosed with psoriasis (group A) were enrolled and compared with healthy non- psoriatic age- and sex-matched subjects (group B). The severity of the disease, CV risk factors, including anthropometric data with adiposity and its distribution, blood pressure (BP), laboratory metabolic tests, echocardiography and vascular ultrasound (transcranial echo-Doppler and carotid artery echo-Doppler with carotid intima-media thickness, cIMT) were performed for each subject. Personal history for CV risk, BP, anthropometric data were similar between the two groups, while familiar history for psoriasis was more frequent in group A (p < 0.02). C-IMT was significantly higher in group A compared to B (right, p = 0.001; left, p = 0.002). In addition, c-IMT was positively correlated with disease duration, triglycerides and triglycerides/glucose. Cerebral flow velocities, cardiac measurements, systo-diastolic function, ventricle geometry and mass were normal and comparable between the two groups, and did not correlate with CV risk factors. In childhood psoriasis c-IMT could represent a marker of pre-clinical cardiovascular involvement and contribute to start a personalized management, while cardiac findings seem to be normal in the early stage of disease. Longitudinal studies can clarify the progression of CV involvement in paediatric-onset psoriasis.
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Affiliation(s)
- Marianna Fabi
- Pediatric Emergency Unit, Scientific Institute for Research and Healthcare (IRCCS), Sant'Orsola University Hospital, Via Massarenti, 11, Bologna, Italy
| | - Marco A Chessa
- Dermatology Division, Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), IRCCS University Hospital of Bologna S. Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Davide Panizza
- Pediatric Emergency Unit, Scientific Institute for Research and Healthcare (IRCCS), Sant'Orsola University Hospital, Via Massarenti, 11, Bologna, Italy.
| | - Ada Dormi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Anna Gazzano
- Pediatric Emergency Unit, Scientific Institute for Research and Healthcare (IRCCS), Sant'Orsola University Hospital, Via Massarenti, 11, Bologna, Italy
| | - Annalisa Patrizi
- Dermatology Division, Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), IRCCS University Hospital of Bologna S. Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Federico Bardazzi
- Dermatology Division, Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), IRCCS University Hospital of Bologna S. Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Alessandro Rocca
- Pediatric Emergency Unit, Scientific Institute for Research and Healthcare (IRCCS), Sant'Orsola University Hospital, Via Massarenti, 11, Bologna, Italy
| | - Emanuele Filice
- Pediatric Emergency Unit, Scientific Institute for Research and Healthcare (IRCCS), Sant'Orsola University Hospital, Via Massarenti, 11, Bologna, Italy
| | - Iria Neri
- Dermatology Division, Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), IRCCS University Hospital of Bologna S. Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Marcello Lanari
- Pediatric Emergency Unit, Scientific Institute for Research and Healthcare (IRCCS), Sant'Orsola University Hospital, Via Massarenti, 11, Bologna, Italy
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Krajina I, Stupin A, Šola M, Mihalj M. Oxidative Stress Induced by High Salt Diet—Possible Implications for Development and Clinical Manifestation of Cutaneous Inflammation and Endothelial Dysfunction in Psoriasis vulgaris. Antioxidants (Basel) 2022; 11:antiox11071269. [PMID: 35883760 PMCID: PMC9311978 DOI: 10.3390/antiox11071269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/19/2022] [Accepted: 06/23/2022] [Indexed: 02/07/2023] Open
Abstract
Although oxidative stress is recognized as an important effector mechanism of the immune system, uncontrolled formation of reactive oxygen and nitrogen species promotes excessive tissue damage and leads to disease development. In view of this, increased dietary salt intake has been found to damage redox systems in the vessel wall, resulting in endothelial dysfunction associated with NO uncoupling, inflammation, vascular wall remodeling and, eventually, atherosclerosis. Several studies have reported increased systemic oxidative stress accompanied by reduced antioxidant capacity following a high salt diet. In addition, vigorous ionic effects on the immune mechanisms, such as (trans)differentiation of T lymphocytes are emerging, which together with the evidence of NaCl accumulation in certain tissues warrants a re-examination of the data derived from in vitro research, in which the ionic influence was excluded. Psoriasis vulgaris (PV), as a primarily Th17-driven inflammatory skin disease with proven inflammation-induced accumulation of sodium chloride in the skin, merits our interest in the role of oxidative stress in the pathogenesis of PV, as well as in the possible beneficial effects that could be achieved through modulation of dietary salt intake and antioxidant supplementation.
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Affiliation(s)
- Ivana Krajina
- Department of Dermatology and Venereology, Osijek University Hospital, J. Huttlera 4, HR-31000 Osijek, Croatia;
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, J. Huttlera 4, HR-31000 Osijek, Croatia
| | - Ana Stupin
- Scientific Center of Excellence for Personalized Health Care, Josip Juraj Strossmayer University of Osijek, Trg Svetog Trojstva 3, HR-31000 Osijek, Croatia;
- Institute and Department of Physiology and Immunology, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, J. Huttlera 4, HR-31000 Osijek, Croatia
| | - Marija Šola
- Department of Dermatology and Venereology, Osijek University Hospital, J. Huttlera 4, HR-31000 Osijek, Croatia;
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, J. Huttlera 4, HR-31000 Osijek, Croatia
- Correspondence: (M.Š.); (M.M.); Tel.: +385-31-512-800 (M.M.)
| | - Martina Mihalj
- Department of Dermatology and Venereology, Osijek University Hospital, J. Huttlera 4, HR-31000 Osijek, Croatia;
- Scientific Center of Excellence for Personalized Health Care, Josip Juraj Strossmayer University of Osijek, Trg Svetog Trojstva 3, HR-31000 Osijek, Croatia;
- Institute and Department of Physiology and Immunology, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, J. Huttlera 4, HR-31000 Osijek, Croatia
- Correspondence: (M.Š.); (M.M.); Tel.: +385-31-512-800 (M.M.)
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3
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Wegner J, Karbach S, Drosos I, Schnorbus B, Muxel S, Schmidt F, Wenzel P, Waisman A, Münzel T, Gori T, von Stebut E. TNF-α blockade may lead to improvement of vascular function in psoriasis patients. Exp Dermatol 2021; 31:237-241. [PMID: 34432926 DOI: 10.1111/exd.14452] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 06/28/2021] [Accepted: 08/13/2021] [Indexed: 01/01/2023]
Abstract
Psoriasis is one of the most common chronic inflammatory skin diseases and at the same time a risk factor for cardiovascular disease. Interleukin-17A (IL-17A)-mediated inflammation in psoriasis may lead to vascular dysfunction. This study aimed at investigating whether anti-inflammatory treatment by tumor necrosis factor (TNF)-α blockade alters vascular function in psoriasis patients. A total of 11 patients with psoriasis who underwent treatment with either adalimumab (n = 8) or etanercept (n = 3), 10 healthy control individuals and 14 patients with coronary artery disease (CAD) were included in this study. Treatment response was assessed using the Psoriasis Area and Severity Index (PASI) score. Endothelial reactivity and resting endothelium-dependent vascular tone were assessed by ultrasound measurement of flow-mediated dilation (FMD) and low-flow-mediated constriction (l-FMC), respectively. FMD was slightly impaired in psoriasis patients compared to healthy controls. Anti-TNF-α treatment did not significantly change FMD levels. Psoriasis patients showed a trend towards increased baseline vascular activity compared to healthy controls. Anti-TNF-α treatment significantly improved l-FMC in psoriasis patients. Noteworthy, both FMD and l-FMC in psoriasis patients were comparable to those in patients with CAD; however, an important influence of age differences between the groups or co-existent classical cardiovascular risk factors on FMD and l-FMC cannot be ruled out by our small study. The results suggest that anti-inflammatory treatment with TNF-α blockade improves vascular function in patients with psoriasis, mainly by altering baseline vascular tone. Further studies will be necessary to establish the potentially protective impact of anti-inflammatory therapy on vascular function in patients with chronic inflammatory diseases.
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Affiliation(s)
- Joanna Wegner
- Department of Dermatology, University Medical Center Mainz, Mainz, Germany
| | - Susanne Karbach
- Center of Cardiology, Cardiology 1, University Medical Center Mainz, Mainz, Germany.,Center of Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany.,German Center for Cardiovascular Research (DZHK, Greifswald, Germany
| | - Ioannis Drosos
- Center of Cardiology, Cardiology 1, University Medical Center Mainz, Mainz, Germany
| | - Boris Schnorbus
- Center of Cardiology, Cardiology 1, University Medical Center Mainz, Mainz, Germany
| | - Selina Muxel
- Center of Cardiology, Cardiology 1, University Medical Center Mainz, Mainz, Germany
| | - Frank Schmidt
- Center of Cardiology, Cardiology 1, University Medical Center Mainz, Mainz, Germany
| | - Philip Wenzel
- Center of Cardiology, Cardiology 1, University Medical Center Mainz, Mainz, Germany.,Center of Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany.,German Center for Cardiovascular Research (DZHK, Greifswald, Germany
| | - Ari Waisman
- Institute of Molecular Medicine, University Medical Center Mainz, Mainzm, Germany
| | - Thomas Münzel
- Center of Cardiology, Cardiology 1, University Medical Center Mainz, Mainz, Germany.,Center of Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany.,German Center for Cardiovascular Research (DZHK, Greifswald, Germany
| | - Tommaso Gori
- Center of Cardiology, Cardiology 1, University Medical Center Mainz, Mainz, Germany.,German Center for Cardiovascular Research (DZHK, Greifswald, Germany
| | - Esther von Stebut
- Department of Dermatology, University of Cologne, University Hospital Cologne and Faculty of Medicine Cologne, Cologne, Germany
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4
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High prevalence of erectile dysfunction in men with psoriasis: evidence from a systematic review and meta-analysis. Int J Impot Res 2018; 31:74-84. [DOI: 10.1038/s41443-018-0093-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 09/25/2018] [Accepted: 10/15/2018] [Indexed: 02/06/2023]
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5
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Malecic N, Young HS. Excessive angiogenesis associated with psoriasis as a cause for cardiovascular ischaemia. Exp Dermatol 2018; 26:299-304. [PMID: 28156019 DOI: 10.1111/exd.13310] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2017] [Indexed: 01/09/2023]
Abstract
Psoriasis, a common disease affecting 2%-3% of the UK population, produces significant impairment of quality of life and is an immense burden on sufferers and their families. Psoriasis is associated with significant cardiovascular comorbidity and the metabolic syndrome. Angiogenesis, a relatively under-researched component of psoriasis, is a key factor in pathogenesis of psoriasis and also contributes to the development of atherosclerosis. Vascular endothelial growth factor (VEGF) is a well-established mediator of pathological angiogenesis which is upregulated in psoriasis. It is possible that, in patients with psoriasis, cutaneous angiogenesis may be both a marker for systemic vascular pathology and a novel therapeutic target. In this viewpoint study, the role of VEGF-mediated angiogenesis as a cause for cardiovascular events in patients with psoriasis is explored.
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Affiliation(s)
- Nina Malecic
- Manchester Academic Health Science Centre, Department of Dermatology, The University of Manchester, Manchester, UK
| | - Helen S Young
- Manchester Academic Health Science Centre, Department of Dermatology, The University of Manchester, Manchester, UK
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6
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Abstract
The association between psoriasis and carotid intima-media thickness (CIMT) or impaired flow-mediated dilation (FMD) remains controversial. We aimed to evaluate the extent of subclinical atherosclerosis as measured by CIMT and FMD in patients with psoriasis by conducting a meta-analysis.A systematic literature search was performed using PubMed, Embase, Cochrane databases, China National Knowledge Infrastructure, and VIP databases up to February 2015. Observational studies investigating CIMT or FMD in patients with psoriasis and controls were eligible. Psoriatic patients and controls were at least age- and sex-matched. Random-effects analysis was used to estimate the weighted mean difference (WMD) and 95% confidence interval (CI) between psoriatic patients and controls.A total of 20 studies were identified and analyzed. Meta-analysis showed that psoriatic patients had a significantly thicker CIMT (WMD 0.11 mm; 95% CI 0.08-0.15) and lower FMD (WMD -2.79%; -4.14% to -1.43%) than those in controls. Subgroup analysis indicated that psoriatic arthritis appeared to have less impaired FMD (WMD -2.45%) and thinner CIMT (WMD 0.10 mm). Psoriatic patients with mean age >45 years had much thicker CIMT (WMD 0.13 mm). The impaired FMD (WMD -3.99%) seemed more pronounced in psoriatic patients with mean age <45 years.This meta-analysis suggests that patients with psoriasis are associated with excessive risk of subclinical atherosclerosis. Screening and monitoring CIMT and brachial artery FMD may be recommended to identify a subgroup of psoriatic patients at higher risk for cardiovascular events.
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Affiliation(s)
- Na Fang
- From the Institute of Molecular Biology & Translational Medicine, the Affiliated People's Hospital, Jiangsu University, Zhenjiang, Jiangsu, PR China
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Pina T, Corrales A, Lopez-Mejias R, Armesto S, Gonzalez-Lopez MA, Gómez-Acebo I, Ubilla B, Remuzgo-Martínez S, Gonzalez-Vela MC, Blanco R, Hernández JL, Llorca J, Gonzalez-Gay MA. Anti-tumor necrosis factor-alpha therapy improves endothelial function and arterial stiffness in patients with moderate to severe psoriasis: A 6-month prospective study. J Dermatol 2016; 43:1267-1272. [DOI: 10.1111/1346-8138.13398] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 02/27/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Trinitario Pina
- Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases; Rheumatology Division; Hospital Universitario Marqués de Valdecilla; University of Cantabria; Santander Spain
| | - Alfonso Corrales
- Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases; Rheumatology Division; Hospital Universitario Marqués de Valdecilla; University of Cantabria; Santander Spain
| | - Raquel Lopez-Mejias
- Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases; Rheumatology Division; Hospital Universitario Marqués de Valdecilla; University of Cantabria; Santander Spain
| | - Susana Armesto
- Dermatology Division; IDIVAL; Hospital Universitario Marqués de Valdecilla; University of Cantabria; Santander Spain
| | - Marcos A. Gonzalez-Lopez
- Dermatology Division; IDIVAL; Hospital Universitario Marqués de Valdecilla; University of Cantabria; Santander Spain
| | - Ines Gómez-Acebo
- Department of Epidemiology and Computational Biology; School of Medicine; IDIVAL; University of Cantabria and CIBER Epidemiología y Salud Pública (CIBERESP); Hospital Universitario Marqués de Valdecilla; University of Cantabria; Santander Spain
| | - Begoña Ubilla
- Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases; Rheumatology Division; Hospital Universitario Marqués de Valdecilla; University of Cantabria; Santander Spain
| | - Sara Remuzgo-Martínez
- Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases; Rheumatology Division; Hospital Universitario Marqués de Valdecilla; University of Cantabria; Santander Spain
| | - M. Carmen Gonzalez-Vela
- Pathology Division; Hospital Universitario Marqués de Valdecilla; University of Cantabria; Santander Spain
| | - Ricardo Blanco
- Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases; Rheumatology Division; Hospital Universitario Marqués de Valdecilla; University of Cantabria; Santander Spain
| | - Jose L. Hernández
- Department of Internal Medicine; IDIVAL; Hospital Universitario Marqués de Valdecilla; University of Cantabria; Santander Spain
| | - Javier Llorca
- Dermatology Division; IDIVAL; Hospital Universitario Marqués de Valdecilla; University of Cantabria; Santander Spain
| | - Miguel A. Gonzalez-Gay
- Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases; Rheumatology Division; Hospital Universitario Marqués de Valdecilla; University of Cantabria; Santander Spain
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8
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Cohen-Barak E, Sah M, Kerner M, Rozenman D, Ziv M. Impact of antipsoriatic therapy on endothelial function. Br J Dermatol 2015; 173:1440-6. [DOI: 10.1111/bjd.14076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2015] [Indexed: 02/02/2023]
Affiliation(s)
- E. Cohen-Barak
- Department of Dermatology; Haemek Medical Center; Afula 18101 Israel
| | - M. Sah
- Department of Dermatology; Haemek Medical Center; Afula 18101 Israel
| | - M. Kerner
- Department of Dermatology; Haemek Medical Center; Afula 18101 Israel
| | - D. Rozenman
- Department of Dermatology; Haemek Medical Center; Afula 18101 Israel
| | - M. Ziv
- Department of Dermatology; Haemek Medical Center; Afula 18101 Israel
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9
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Mancini GBJ. The fire within psoriatic patients: overlap between inflammatory and cardiovascular diseases. Can J Cardiol 2015; 31:242-3. [PMID: 25592850 DOI: 10.1016/j.cjca.2014.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 11/14/2014] [Indexed: 10/24/2022] Open
Affiliation(s)
- G B John Mancini
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.
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10
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Erfan G, Guzel S, Alpsoy S, Rifaioglu EN, Kaya S, Kucukyalcın V, Topcu B, Kulac M. Serum YKL-40: a potential biomarker for psoriasis or endothelial dysfunction in psoriasis? Mol Cell Biochem 2014; 400:207-12. [PMID: 25421412 DOI: 10.1007/s11010-014-2277-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 11/15/2014] [Indexed: 12/15/2022]
Abstract
Psoriasis is a disease that can contribute to a risk of atherosclerosis. In several studies, impaired endothelial dysfunction (ED) is correlated with psoriasis. Serum YKL-40 is a new inflammatory biomarker of vascular damage, like ED and cardiovascular diseases. The aim of the study was to compare relevance of serum YKL-40 levels in psoriasis patients and healthy subjects according to ED diagnosis and identifiable cardiovascular risk factors. Sixty (31 female, 29 male) patients with plaque psoriasis, and 30 (18 female, 12 male) healthy controls were selected according to whether they had at least one or no identifiable risk factors for cardiovascular disease. All subjects were evaluated ultrasonographically for endothelial function and diagnosed as with or without ED and all groups compared for serum YKL-40 levels. YKL-40 levels of psoriatic patients with ED were higher than healthy controls with ED (P = <0.05). There were no statistical differences in between subjects without ED. YKL-40 levels of patients over age of 40 were higher than younger ones (P < 0.05). But in healthy controls, there were no differences. In comparison of cardiovascular risk-positive (RP) patients and RP healthy subjects, YKL-40 levels were higher in RP patients (P = <0.05). The elevation of plasma YKL-40 in psoriasis can be associated not only with inflammation of the disease, but also with ED. YKL-40 can be used as a marker for predicting and preventing cardiovascular diseases in RP psoriatic patients with age above 40.
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Affiliation(s)
- Gamze Erfan
- Department of Dermatology, Faculty of Medicine, Namık Kemal University, Tunca Cad. 100. Yıl Mah., Tekirdag, Turkey,
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11
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Steyers CM, Miller FJ. Endothelial dysfunction in chronic inflammatory diseases. Int J Mol Sci 2014; 15:11324-49. [PMID: 24968272 PMCID: PMC4139785 DOI: 10.3390/ijms150711324] [Citation(s) in RCA: 298] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 05/23/2014] [Accepted: 06/06/2014] [Indexed: 12/13/2022] Open
Abstract
Chronic inflammatory diseases are associated with accelerated atherosclerosis and increased risk of cardiovascular diseases (CVD). As the pathogenesis of atherosclerosis is increasingly recognized as an inflammatory process, similarities between atherosclerosis and systemic inflammatory diseases such as rheumatoid arthritis, inflammatory bowel diseases, lupus, psoriasis, spondyloarthritis and others have become a topic of interest. Endothelial dysfunction represents a key step in the initiation and maintenance of atherosclerosis and may serve as a marker for future risk of cardiovascular events. Patients with chronic inflammatory diseases manifest endothelial dysfunction, often early in the course of the disease. Therefore, mechanisms linking systemic inflammatory diseases and atherosclerosis may be best understood at the level of the endothelium. Multiple factors, including circulating inflammatory cytokines, TNF-α (tumor necrosis factor-α), reactive oxygen species, oxidized LDL (low density lipoprotein), autoantibodies and traditional risk factors directly and indirectly activate endothelial cells, leading to impaired vascular relaxation, increased leukocyte adhesion, increased endothelial permeability and generation of a pro-thrombotic state. Pharmacologic agents directed against TNF-α-mediated inflammation may decrease the risk of endothelial dysfunction and cardiovascular disease in these patients. Understanding the precise mechanisms driving endothelial dysfunction in patients with systemic inflammatory diseases may help elucidate the pathogenesis of atherosclerosis in the general population.
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Affiliation(s)
- Curtis M Steyers
- Department of Internal Medicine, University of Iowa, Iowa City, IA 52242, USA.
| | - Francis J Miller
- Department of Internal Medicine, University of Iowa, Iowa City, IA 52242, USA.
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12
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Martyn-Simmons C, Rosenberg W, Cross R, Wong T, Smith C, Barker J. Validity of noninvasive markers of methotrexate-induced hepatotoxicity: a retrospective cohort study. Br J Dermatol 2014; 171:267-73. [DOI: 10.1111/bjd.12782] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2013] [Indexed: 01/06/2023]
Affiliation(s)
- C.L. Martyn-Simmons
- Division of Genetics and Molecular Medicine; St John's Institute of Dermatology; King's College London and Guy's and St Thomas' NHS Foundation Trust; London U.K
| | - W.M.C. Rosenberg
- Division of Medicine; Institute for Liver and Digestive Health; University College London; London U.K
| | - R. Cross
- iQur Ltd; Wolfson Laboratory; Royal Free Hospital; London U.K
| | - T. Wong
- Department of Gastroenterology; King's College London and Guy's and St Thomas' NHS Foundation Trust; London U.K
| | - C.H. Smith
- Division of Genetics and Molecular Medicine; St John's Institute of Dermatology; King's College London and Guy's and St Thomas' NHS Foundation Trust; London U.K
| | - J.N.W.N. Barker
- Division of Genetics and Molecular Medicine; St John's Institute of Dermatology; King's College London and Guy's and St Thomas' NHS Foundation Trust; London U.K
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13
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Coimbra S, Santos-Silva A. Biomarkers of psoriasis severity and therapy monitoring. World J Dermatol 2014; 3:15-27. [DOI: 10.5314/wjd.v3.i2.15] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 01/13/2014] [Accepted: 02/18/2014] [Indexed: 02/06/2023] Open
Abstract
Psoriasis is a chronic, recurrent inflammatory cutaneous disease. Psoriasis patients alternate between periods of remission and periods of exacerbation of the disease. Usually, psoriasis severity is clinically evaluated using tools like Psoriasis Area and Severity Index that present some limitations and subjectivity. Clinicians select the therapy according to psoriasis severity, aiming that patients achieve longer remission periods and improve their quality of life. Biological markers for diagnosis and prognosis of psoriasis help to establish its severity and to monitor the therapeutic response; moreover, biomarkers of psoriasis assist clinicians in their therapeutic decision to treat psoriasis and to choose earlier and more adequate therapeutic strategies, avoiding or minimising worsening of psoriasis. With these markers, they would be able to monitor therapeutics, avoiding unnecessary therapeutic surcharge or changes to a more aggressive therapy. As any attempt to identify these biomarkers should be encouraged, in this review, we will debate published data concerning the proposal of biomarkers to evaluate severity and response to treatment of psoriasis vulgaris.
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Dowlatshahi EA, van der Voort EAM, Arends LR, Nijsten T. Markers of systemic inflammation in psoriasis: a systematic review and meta-analysis. Br J Dermatol 2014; 169:266-82. [PMID: 23550658 DOI: 10.1111/bjd.12355] [Citation(s) in RCA: 160] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2013] [Indexed: 12/15/2022]
Abstract
Studies investigating systemic inflammation in psoriasis use different serum markers and report discrepant results. We set out to determine whether systemic inflammation is elevated in patients with psoriasis compared with healthy controls, and to measure the extent of this elevation, by summarizing available data on serum inflammatory markers. PubMed, Embase and Web of Science were searched from inception to March 2011. We included studies comparing the serum inflammatory markers interleukin (IL)-1β, IL-6, IL-10, C-reactive protein (CRP), intracellular adhesion molecule (ICAM)-1, E-selectin and tumour necrosis factor (TNF)-α in patients with psoriasis and healthy controls. Differences in serum marker levels between patients and controls were pooled as standardized mean differences (SMDs; Cohen's d) using a random-effects model. Seventy-eight studies were eligible. Of the 7852 individuals included, 3085 had (severe plaque) psoriasis. The pooled SMDs were higher in patients with psoriasis than in healthy controls for IL-6 [d = 1·32, 95% confidence interval (CI) 0·83-1·81], CRP (d = 1·83, 95% CI 0·76-2·90), TNF-α (d = 1·32, 95% CI 0·86-1·79), E-selectin (d = 1·78, 95% CI 1·32-2·25) and ICAM-1 (d = 1·77, 95% CI 1·15-2·39). The SMD between cases and controls for IL-1β and IL-10 was not significant. Age had a significant effect on the SMD for IL-6 and TNF-α. For IL-6 the effect size was higher for plaque psoriasis studies (d = 1·98). The effect size was not influenced by the Psoriasis Area and Severity Index, measurement method or quality assessment. The pooled analyses suggest modest but significantly elevated levels of the proinflammatory cytokines in the serum of patients with psoriasis with predominantly severe disease. To what extent this modest increment is clinically relevant could be investigated in a synthesis of all studies measuring inflammation before and after antipsoriatic therapy.
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Affiliation(s)
- E A Dowlatshahi
- Department of Dermatology , Erasmus Medical Centre, Rotterdam, the Netherlands
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Maybury CM, Barker JN, Smith CH. Psoriasis and cardiovascular disease: where is the risk? J Invest Dermatol 2013; 133:2308-2311. [PMID: 24030646 DOI: 10.1038/jid.2013.207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
In this issue, Dowlatshahi et al. publish results from their population-based study in Rotterdam showing that, despite an increase in body mass index and smoking, individuals with psoriasis have no increased risk of incident cardiovascular disease. These results should be interpreted with caution: the study included relatively small numbers of patients with psoriasis, most of whom had mild disease.
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Affiliation(s)
| | - Jonathan N Barker
- St John's Institute of Dermatology, King's College London, London, UK
| | - Catherine H Smith
- St John's Institute of Dermatology, King's College London, London, UK
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Shaharyar S, Warraich H, McEvoy JW, Oni E, Ali SS, Karim A, Jamal O, Blaha MJ, Blumenthal RS, Fialkow J, Cury R, Budoff MJ, Agatston AA, Nasir K. Subclinical cardiovascular disease in plaque psoriasis: association or causal link? Atherosclerosis 2013; 232:72-8. [PMID: 24401219 DOI: 10.1016/j.atherosclerosis.2013.10.023] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 10/19/2013] [Accepted: 10/21/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Psoriasis patients have a high prevalence of cardiovascular events and are thought to have a relative risk increase of 25% as compared to the general population. However, a causal relationship between psoriasis and cardiovascular disease has not been established. We sought to perform a systematic review of existing data regarding the presence of endothelial dysfunction and subclinical atherosclerosis in patients with plaque psoriasis. METHODS A systematic literature search was performed, using Medline database and Ovid SP for relevant literature up to November 2012. Twelve studies met inclusion criteria from an initial search result of 529 articles. RESULTS Among the twelve studies meeting inclusion criteria, two (17%) reported increased mean coronary artery calcification (CAC) in psoriatic patients. Six studies (50%) showed carotid intima-media thickness [CIMT] increase in psoriasis. Five studies (42%) examined flow mediated dilation [FMD], of which three showed decreased FMD in psoriasis patients. One study (8%) each demonstrated a decreased coronary flow reserve and increased arterial stiffness as assessed by pulse wave velocity. CONCLUSIONS Patients with psoriasis have an increased burden of subclinical atherosclerosis and endothelial dysfunction. Patients with greater severity and/or disease duration should be targeted for primary screening for cardiovascular disease risk reduction.
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Affiliation(s)
- Sameer Shaharyar
- Center for Prevention and Wellness Research, Baptist Health Medical Group, Miami Beach, FL, USA
| | - Haider Warraich
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - John W McEvoy
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA
| | - Ebenezer Oni
- Center for Prevention and Wellness Research, Baptist Health Medical Group, Miami Beach, FL, USA
| | - Shozab S Ali
- Center for Prevention and Wellness Research, Baptist Health Medical Group, Miami Beach, FL, USA
| | - Adil Karim
- Center for Prevention and Wellness Research, Baptist Health Medical Group, Miami Beach, FL, USA
| | - Omar Jamal
- Center for Prevention and Wellness Research, Baptist Health Medical Group, Miami Beach, FL, USA
| | - Michael J Blaha
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA
| | - Roger S Blumenthal
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA
| | - Jonathan Fialkow
- Baptist Hospital of Miami and Baptist Cardiac & Vascular Institute, Miami, FL, USA
| | - Ricardo Cury
- Baptist Hospital of Miami and Baptist Cardiac & Vascular Institute, Miami, FL, USA; Department of Radiology, Florida International University, Miami, FL, USA
| | - Matthew J Budoff
- Los Angeles Biomedical Research Institute, UCLA Harbor Medical Center, CA, USA
| | - Arthur A Agatston
- Center for Prevention and Wellness Research, Baptist Health Medical Group, Miami Beach, FL, USA
| | - Khurram Nasir
- Center for Prevention and Wellness Research, Baptist Health Medical Group, Miami Beach, FL, USA; Department of Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA; The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA; Baptist Hospital of Miami and Baptist Cardiac & Vascular Institute, Miami, FL, USA; Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami, FL, USA.
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Psoriasis Is Not Associated with Atherosclerosis and Incident Cardiovascular Events: The Rotterdam Study. J Invest Dermatol 2013; 133:2347-2354. [DOI: 10.1038/jid.2013.131] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 02/07/2013] [Accepted: 02/08/2013] [Indexed: 12/26/2022]
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Beygi S, Lajevardi V, Abedini R. C-reactive protein in psoriasis: a review of the literature. J Eur Acad Dermatol Venereol 2013; 28:700-11. [PMID: 23998353 DOI: 10.1111/jdv.12257] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 07/26/2013] [Indexed: 12/26/2022]
Abstract
A great deal of research has addressed the elevation of C-reactive protein (CRP) among psoriatic patients and the role of this marker in assessment of disease severity and progression. However, there are some discrepancies in this area. We sought to figure out the relationship between CRP values and disease severity as well as the changes in marker levels after treatment through an extensive literature review. Comparison between CRP levels in psoriatic patients and those in healthy or non-psoriatic individuals was also another focus of this review. A thorough search in Pubmed and Embase was conducted for articles investigating different aspects of CRP measurement in patients with psoriasis. Overall, 32 articles were found to meet our inclusion criteria. Of 28 studies comparing the CRP values in psoriatic patients with those of controls, 24 found a statistically significant difference. In addition, 12 out of 16 papers examining the association between disease severity and CRP values noted significant results. With regard to CRP changes over the course of a treatment, all 15 studies addressing this issue revealed a significant decrease in marker levels. In conclusion, high CRP levels only for moderate and severe forms of disease might be inferred from the literature and there is no sufficient evidence suggesting a similar association for mild disease as well. Moreover, CRP may serve interchangeably with Psoriasis Area and Severity Index (PASI) as a measure of disease severity in the case of untreated psoriatic patients who do not have disease related arthritis. For other patients, however, a careful clinical examination and PASI calculation still remain the mainstay of severity assessment.
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Affiliation(s)
- S Beygi
- Autoimmune Bullous Diseases Research Center, Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran; National Elite Foundation, Tehran, Iran
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Pietrzak A, Bartosińska J, Chodorowska G, Szepietowski JC, Paluszkiewicz P, Schwartz RA. Cardiovascular aspects of psoriasis: an updated review. Int J Dermatol 2013; 52:153-62. [PMID: 23347301 DOI: 10.1111/j.1365-4632.2012.05584.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Psoriasis, a systemic inflammatory disease, is associated with enhanced atherosclerosis and risk of cardiovascular (CV) disease, which may account for higher morbidity and mortality rates in psoriatic patients. It especially applies to younger psoriatic patients with more severe disease, reducing their life expectancy. The aim of the study was to review the literature on CV disease in psoriasis as well as the pathogenic mechanisms shared between psoriasis and atherosclerosis. Moreover, case-control and cohort studies published between 2006 and 2011 were selected for meta-analysis. The meta-analysis indicates elevated risk of cardiovascular events in psoriatic patients in relation to non-psoriatic controls (OR 1.28; 95% CI 1.18-1.38). It is suggested that the treatment of the inflammatory processes involved in the pathogenesis of both psoriasis and atherosclerosis may be beneficial in reducing the CV risk in psoriatic patients. Further in-depth investigations, including prospective studies, are needed to enable more effective management of psoriatic patients in the future.
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Affiliation(s)
- Aldona Pietrzak
- Department of Dermatology, Medical University of Lublin, Lublin, Poland
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De Simone C, Caldarola G, Coco V, Palumbo S, Pocino K, Sgambato A, Maiorino A, Corbi M, Sandri MT, Vendittelli F, Capoluongo E. Circulating endothelial cell levels in psoriatic patients and their modification after an anti-TNF-alpha (Etanercept) treatment. J Eur Acad Dermatol Venereol 2013; 28:590-6. [PMID: 23506557 DOI: 10.1111/jdv.12140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2012] [Accepted: 02/18/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Endothelial function in psoriatic patients has been mainly evaluated through a high-resolution ultrasound measurement of flow-mediated vasodilation in the brachial artery, which is an operator-dependent and technically demanding technique: this characteristic, together with different patient selection criteria, could account for the conflicting results emerging from different studies. Recently, Circulating Endothelial Cells (CECs) level has been suggested as a novel biomarker of vascular injury. METHODS The number of CECs was determined by a semi-automated immunomagnetic system (CellSearch system) in peripheral blood of psoriatic patients (n = 48) and healthy subjects (n = 50). In 15 patients, CEC level was also evaluated after 6 months of treatment with an anti-TNF-alpha agent, Etanercept. The plasma levels of high-sensitivity C-reactive Protein (CRP), E-selectin, VEGF and PAI-1 were measured by ELISA. The psoriasis severity was assessed by PASI score. RESULTS A statistically significant difference (P = 0.001) was found between CEC level in psoriatic patients (10.6 ± 9.4 cells/mL) vs. the control group (3.9 ± 0.9 cells/mL). This count inversely correlated with sE-selectin levels (r(2) = 0.16; P = 0.03). After 6 months of therapy, patients experienced a significant (P < 0.05) decrease in CEC levels (3.4 ± 1.3 cells/mL) and in PASI score (from 11.7 ± 8.1 to 2.1 ± 4.0). CONCLUSIONS The elevated CECs level that we found in a sample of high selected psoriatic patients could be expression of endothelial damage. Lowering of CECs count after treatment with Etanercept support the hypothesis that an effective systemic therapy of psoriasis may also improve the endothelial function.
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Affiliation(s)
- C De Simone
- Department of Dermatology, Catholic University of the Sacred Heart, Rome, Italy
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Papadavid E, Vlami K, Dalamaga M, Giatrakou S, Theodoropoulos K, Gyftopoulos S, Stavrianeas N, Papiris S, Rigopoulos D. Sleep apnea as a comorbidity in obese psoriasis patients: a cross-sectional study. Do psoriasis characteristics and metabolic parameters play a role? J Eur Acad Dermatol Venereol 2012; 27:820-6. [PMID: 22620285 DOI: 10.1111/j.1468-3083.2012.04580.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Psoriasis is associated with a variety of comorbidities such as obesity and cardiovascular disease. OBJECTIVE In a cross-sectional study, we explored whether obstructive sleep apnea and hypopnea syndrome (OSAHS) is associated with psoriasis characteristics and metabolic parameters. METHODS Thirty-five patients with chronic plaque psoriasis underwent a nocturnal polysomnography study and were analysed for Apnoea-Hypopnoea Index to assess OSAHS severity and Framigham score to predict the absolute risk of coronary artery disease at 10 years. The association of OSAHS with psoriasis was examined according to psoriasis characteristics (PASI and DLQI scores, disease duration and previous use of systemic treatments), metabolic parameters (Body Mass Index - BMI, waist to hip ratio - WHR, lipid profile) and other comorbidities (obesity, hypertension, arthritis and cardiovascular disease). RESULTS There was no correlation between psoriasis characteristics and OSAHS. Psoriasis patients with OSAHS presented more frequent snoring and lower sleep quality compared with those without OSAHS. In univariate analyses, OSAHS was associated with increased BMI and hypertension in psoriasis patients. In multivariable logistic regression models, there was statistically significant evidence that only BMI and hypertension were associated with increased risk of OSAHS, adjusting for psoriasis characteristics, age and gender. Presence of metabolic syndrome, WHR, and smoking were not significant risk factors for OSAHS. In subgroup analyses, OSAHS correlated with duration of psoriasis (>8 years) in women (P = 0.021) and with Framigham score in men (P = 0.035). CONCLUSION OSAHS may be a comorbidity in obese psoriasis patients with hypertension. Treatment with continuous positive airway pressure and weight loss interventions should be initiated.
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Affiliation(s)
- E Papadavid
- Department of Dermatology, Athens University Medical School, ΑΤΤΙΚΟΝ General University Hospital, Haidari, Athens, Greece.
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Chung SD, Keller JJ, Chu TW, Lin HC. Psoriasis and the risk of erectile dysfunction: a population-based case-control study. J Sex Med 2011; 9:130-5. [PMID: 22023713 DOI: 10.1111/j.1743-6109.2011.02510.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Psoriasis is associated with systemic metabolic and cardiovascular disorders, both of which share risk factors with erectile dysfunction (ED). However, few studies have investigated the association between ED and psoriasis. AIM This study set out to estimate the association between ED and having previously been diagnosed with psoriasis by using a population-based dataset with a case-control design. METHODS This study used administrative claim data from the Taiwan National Health Insurance program. We identified 4,606 patients with ED as the study group and randomly selected 13,818 patients as the comparison group. Conditional logistic regression was used to examine the association between ED and having previously received a diagnosis of psoriasis. MAIN OUTCOME MEASURE The prevalence and risk of psoriasis between cases and controls were calculated. RESULTS Of the sampled patients, 136 (0.7%) had been diagnosed with psoriasis before the index date: 77 (1.7% of the cases) were from the study group and 59 (0.4% of controls) were from the control group. Conditional logistic regression analysis revealed that after adjusting for the patient's monthly income, geographic location, hypertension, diabetes, hyperlipidemia, coronary heart disease, obesity, and alcohol abuse/alcohol dependence syndrome status, patients with ED were more likely to have been diagnosed with psoriasis before the index date than controls (odds ratio = 3.85; 95% confidence interval = 2.72-5.44). CONCLUSIONS There was an association between ED and prior psoriasis. The results of this study highlight a need for clinicians dealing with psoriasis patients to be alert to the development of ED.
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Affiliation(s)
- Shiu-Dong Chung
- Division of Urology, Department of Surgery, Far Eastern Memorial Hospital, Ban Ciao, Taipei, Taiwan
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Martyn‐Simmons C, Smith C, Barker J. Psoriasis, cardiovascular disease and flow‐mediated dilatation: reply from authors. Br J Dermatol 2011. [DOI: 10.1111/j.1365-2133.2011.10500.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- C.L. Martyn‐Simmons
- St John’s Institute of Dermatology, Division of Genetics and Molecular Medicine, King’s College London & Guy’s and St Thomas’ NHS Foundation Trust, London, U.K
| | - C.H. Smith
- St John’s Institute of Dermatology, Division of Genetics and Molecular Medicine, King’s College London & Guy’s and St Thomas’ NHS Foundation Trust, London, U.K
| | - J.N.W.N. Barker
- St John’s Institute of Dermatology, Division of Genetics and Molecular Medicine, King’s College London & Guy’s and St Thomas’ NHS Foundation Trust, London, U.K
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Aldeen T, Khorshid M. Psoriasis, cardiovascular disease and flow‐mediated dilatation. Br J Dermatol 2011; 165:923-4; author reply 924-5. [DOI: 10.1111/j.1365-2133.2011.10499.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- T. Aldeen
- Dermatology Department, Basildon Hospital, Basildon SS16 5NL, U.K.
E‐mail:
| | - M. Khorshid
- Dermatology Department, Basildon Hospital, Basildon SS16 5NL, U.K.
E‐mail:
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Martyn-Simmons C, Smith C, Barker J. Systemic antipsoriatic therapy may reverse endothelial dysfunction: reply from authors. Br J Dermatol 2011. [DOI: 10.1111/j.1365-2133.2011.10251.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Actualités – Psoriasis. Ann Dermatol Venereol 2011; 138:H1-5. [DOI: 10.1016/s0151-9638(11)70060-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Boehncke WH, Boehncke S. Systemic antipsoriatic therapy may reverse endothelial dysfunction. Br J Dermatol 2011; 164:1397-8; author reply 1398. [DOI: 10.1111/j.1365-2133.2011.10250.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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